Medicare flags this nursing home for abuse. Medicare adds this flag when a home was cited for abuse that harmed a resident, or for potential abuse more than once. Ask the home what changed.
Inspection citations
20’23
43’24
51’25
7’26
121 shown
| Date | Severity | What inspectors found | Visit |
|---|---|---|---|
| Jun 8, 2026 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Jun 8, 2026 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Apr 28, 2026 | D · potential | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Complaint |
| Jan 28, 2026 | E · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Complaint |
| Jan 28, 2026 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Jan 28, 2026 | E · potential | Provide safe, appropriate pain management for a resident who requires such services. | Complaint |
| Jan 9, 2026 | D · potential | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Complaint |
| Dec 31, 2025 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Dec 18, 2025 | D · potential | Reasonably accommodate the needs and preferences of each resident. | Routine |
| Dec 18, 2025 | D · potential | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Routine |
| Dec 18, 2025 | F · potential | Keep residents' personal and medical records private and confidential. | Routine |
| Dec 18, 2025 | D · potential | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Routine |
| Dec 18, 2025 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Routine |
| Dec 18, 2025 | D · potential | Ensure each resident receives an accurate assessment. | Routine |
| Dec 18, 2025 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Dec 18, 2025 | E · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Routine |
| Dec 18, 2025 | G · harm | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Routine |
| Dec 18, 2025 | G · harm | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Routine |
| Dec 18, 2025 | D · potential | Provide enough food/fluids to maintain a resident's health. | Routine |
| Dec 18, 2025 | E · potential | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Routine |
| Dec 18, 2025 | E · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Dec 18, 2025 | D · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| Dec 18, 2025 | D · potential | Ensure that residents are free from significant medication errors. | Routine |
| Dec 18, 2025 | E · potential | Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Routine |
| Dec 18, 2025 | E · potential | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Routine |
| Dec 18, 2025 | E · potential | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Routine |
| Dec 18, 2025 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Dec 18, 2025 | D · potential | Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Routine |
| Dec 18, 2025 | D · potential | Provide and implement an infection prevention and control program. | Routine |
| Dec 18, 2025 | B · minimal | Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Routine |
| Dec 18, 2025 | E · potential | Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Routine |
| Dec 18, 2025 | D · potential | Provide bedrooms that don't allow residents to see each other when privacy is needed. | Routine |
| Dec 18, 2025 | D · potential | Make sure that a working call system is available in each resident's bathroom and bathing area. | Routine |
| Dec 18, 2025 | D · potential | Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | Routine |
| Aug 28, 2025 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Complaint |
| Aug 27, 2025 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Aug 27, 2025 | D · potential | Provide safe and appropriate respiratory care for a resident when needed. | Complaint |
| Jul 31, 2025 | E · potential | Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. | Complaint |
| Jul 30, 2025 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| Jul 16, 2025 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Jul 16, 2025 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Jul 8, 2025 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Complaint |
| Jul 8, 2025 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Jun 24, 2025 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Complaint |
| Jun 24, 2025 | D · potential | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Complaint |
| Jun 24, 2025 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| Jun 13, 2025 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| Jun 13, 2025 | J · harm | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| May 9, 2025 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Apr 21, 2025 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Apr 16, 2025 | D · potential | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Complaint |
| Mar 17, 2025 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Mar 17, 2025 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Feb 20, 2025 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Feb 20, 2025 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Complaint |
| Feb 4, 2025 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Feb 4, 2025 | D · potential | Provide safe, appropriate dialysis care/services for a resident who requires such services. | Complaint |
| Feb 4, 2025 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Complaint |
| Nov 7, 2024 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Complaint |
| Nov 7, 2024 | D · potential | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Complaint |
| Oct 4, 2024 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Routine |
| Oct 4, 2024 | E · potential | Reasonably accommodate the needs and preferences of each resident. | Routine |
| Oct 4, 2024 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Routine |
| Oct 4, 2024 | E · potential | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Routine |
| Oct 4, 2024 | D · potential | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Routine |
| Oct 4, 2024 | E · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Oct 4, 2024 | D · potential | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Routine |
| Oct 4, 2024 | D · potential | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Routine |
| Oct 4, 2024 | E · potential | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Routine |
| Oct 4, 2024 | E · potential | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Routine |
| Oct 4, 2024 | E · potential | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Routine |
| Oct 4, 2024 | E · potential | Provide safe and appropriate respiratory care for a resident when needed. | Routine |
| Oct 4, 2024 | D · potential | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Routine |
| Oct 4, 2024 | E · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Oct 4, 2024 | D · potential | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Routine |
| Oct 4, 2024 | E · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| Oct 4, 2024 | E · potential | Ensure that residents are free from significant medication errors. | Routine |
| Oct 4, 2024 | E · potential | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Routine |
| Oct 4, 2024 | E · potential | Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Routine |
| Oct 4, 2024 | E · potential | Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Routine |
| Oct 4, 2024 | E · potential | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Routine |
| Oct 4, 2024 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Oct 4, 2024 | E · potential | Dispose of garbage and refuse properly. | Routine |
| Oct 4, 2024 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| Oct 4, 2024 | B · minimal | Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Routine |
| Oct 4, 2024 | E · potential | Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Routine |
| Sep 24, 2024 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| Aug 26, 2024 | E · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| Aug 26, 2024 | D · potential | Ensure that residents are free from significant medication errors. | Complaint |
| Aug 2, 2024 | G · harm | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Aug 2, 2024 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Aug 2, 2024 | D · potential | Respond appropriately to all alleged violations. | Complaint |
| Aug 2, 2024 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Aug 2, 2024 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Apr 18, 2024 | D · potential | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Complaint |
| Apr 18, 2024 | D · potential | Provide and implement an infection prevention and control program. | Complaint |
| Apr 12, 2024 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Mar 28, 2024 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Complaint |
| Mar 28, 2024 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Mar 28, 2024 | E · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Feb 5, 2024 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Oct 16, 2023 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Oct 2, 2023 | E · potential | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Routine |
| Oct 2, 2023 | E · potential | Reasonably accommodate the needs and preferences of each resident. | Routine |
| Oct 2, 2023 | D · potential | Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Routine |
| Oct 2, 2023 | D · potential | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Routine |
| Oct 2, 2023 | E · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Oct 2, 2023 | E · potential | Respond appropriately to all alleged violations. | Complaint |
| Oct 2, 2023 | E · potential | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Complaint |
| Oct 2, 2023 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Routine |
| Oct 2, 2023 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Oct 2, 2023 | E · potential | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Routine |
| Oct 2, 2023 | D · potential | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Routine |
| Oct 2, 2023 | E · potential | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Routine |
| Oct 2, 2023 | E · potential | Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Routine |
| Oct 2, 2023 | D · potential | Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Routine |
| Oct 2, 2023 | F · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Oct 2, 2023 | F · potential | Dispose of garbage and refuse properly. | Routine |
| Oct 2, 2023 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| Oct 2, 2023 | B · minimal | Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Routine |
| Oct 2, 2023 | E · potential | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Routine |
Medicare's severity letters: A–C minimal harm, D–F potential for more than minimal harm, G–L actual harm or immediate danger. Source: CMS health deficiencies file, processed October 1, 2026.
Questions to ask on a visit
Lakewood Healthcare Center
12023 Lakewood Blvd., Downey, CA 90242 · (562) 869-0978
Visit date: ____________ Spoke with: ______________________
Record on file
- Certification
- Medicare and Medi-Cal certified skilled nursing facility
- Medicare number (CCN)
- 555099
- Certified beds
- 290
- Legal owner
- The Healthcare Center of Downey LLC
- Part of
- Pacific Healthcare Holdings
Full profile on Medicare's Care Compare. Source: CMS, processed October 1, 2026.
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